group insurance employee enrollment form - Assurant Health

SECTION F –– medical history details (Details for all answers marked “Yes” must be provided below.)(Complete all columns. If more space is needed, attach an additional sheet of paper which must be signed and dated.)Dates ofQuestion D diagnosis Explain Treatment Results/Degree Physician/Specialty/# and Individual diagnosis and/or Include any Hospitalization, of Recovery hospitalLetter (Full Name) and/or Condition Condition Tests or Surgery and Current Status Telephone NumberSECTION G –– Waiver of Coverage(Complete and sign if waiving any or all coverages for self and/or dependents.)All eligible employees and dependents must be listed as either enrolling or waiving coverage when first eligible. If you or any of your eligibledependents do not enroll in John Alden medical coverage when it is first made available and want to enroll in the future, your coverage maybe subject to an extended pre-existing period exclusion. This pre-existing exclusion does not apply to maternity benefits. If you or any of youreligible dependents do not enroll in John Alden dental coverage when it is first made available and want to enroll in the future, your coveragemay be subject to an extended waiting period for certain benefits. For further information on the late addition policy for group employers inyour state, please contact your agent or a John Alden representative.Person(s) Coverage(s) Other EffectiveWaiving to be Waived Coverage(s) Carrier Name(s) ID No.(s) date(s)EmployeeSpouseChild(ren) AllMedicalDentalAllMedicalDental AllMedicalDentalMedicalDentalMedicalDentalMedicalDentalIndicate the type of coverage in effect and for whom.Type of CoverageFor Whom?Spouse’s Employer Plan Employee Spouse Child(ren)Medicare / Medicaid Employee Spouse Child(ren)Tricare Employee Spouse Child(ren)COBRA Employee Spouse Child(ren)Individual Employee Spouse Child(ren)Other, explain: Employee Spouse Child(ren)Neither I nor my dependents have been induced or pressured to decline coverage by my employer, the agent, or John Alden Life Insurance. I and my dependents have waived such coverage of our own accord.Signature:Printed Name:Date of Signature:Date of Full-time Employment:Form JA-2000 3 (5/2007)